Common problems in writing of medical records found at medical insurance verification

Analyzed in this paper are the common problems found in 242 medical records when they were verified by the Medical Insurance Center of our hospital.Problems found in admission records,diagnosis at discharge,disease course and operation records,as well as doctor’s advice,accessory examination and settling account accounted for 1.2%,2.8%,7.4%,and 13%,respectively.Certain countermeasures were proposed for such problems.